Combined Endoscopic Third Ventriculostomy and Endoscopic Biopsy of Pineal Region Lesions: A Review of Diagnostic Yield and Complications

Object. The authors report their experience in six patients presenting with pineal tumors and associated hydrocephalus who underwent an endoscopic biopsy procedure and third ventriculostomy (ETV) in a single setting. The purpose of this report is to discuss the role of neuroendoscopic procedures in the management of pineal region tumors. Methods. A retrospective review of patients undergoing simultaneous ETV and tumor biopsy was ndertaken. Neuroendoscopic surgery was first applied for tumor debulking with tissue diagnosis and gross morphological analysis of the tumor and the intraventricular structures, followed by third ventriculostomy. Subsequent procedures were determined on the basis of verified individual tumors. Results. Over a 2-year interval, 6 patients underwent simultaneous ETV and tumor management. These patients ranged from 6 to 54 years of age (mean 24.3 years). All cases were completed without complications or the need for an additional CSF diversionary procedure within 6 months. The diagnostic yield of the biopsy was 100%. Favorable therapeutic outcomes were obtained in all cases of germinoma and pineoblastoma, with follow-up periods ranging from 6 to 24 months. Conclusion. The majority of our patients with dilated ventricles were treated satisfactorily with effective neuroendoscopic procedures as the initial procedure, avoiding unnecessary craniotomy and promising excellent therapeutic outcomes.

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Pineal region tumors: an optimal approach for simultaneous endoscopic third ventriculostomy and biopsy

Neurosurgical FOCUS ◽

10.3171/2011.2.focus10301 ◽

2011 ◽

Vol 30 (4) ◽

pp. E3 ◽

Cited By ~ 38

Author(s):

Peter F. Morgenstern ◽

Nathan Osbun ◽

Theodore H. Schwartz ◽

Jeffrey P. Greenfield ◽

Apostolos John Tsiouris ◽

...

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Diagnostic Yield ◽

Anterior Commissure ◽

Pineal Region ◽

Third Ventriculostomy ◽

Tumor Biopsy ◽

Pineal Region Tumors ◽

Trajectory Approach ◽

Trajectory Group ◽

Optimal Approach

Object Simultaneous endoscopic third ventriculostomy (ETV) and tumor biopsy is a widely accepted therapeutic and diagnostic procedure for patients with noncommunicating hydrocephalus secondary to a pineal region tumor. Multiple approaches have been advocated, including the use of a steerable fiberoptic or rigid lens endoscope via 1 or 2 trajectories. However, the optimal approach has not been established based on the individual anatomical characteristics of the patient. Methods A retrospective review of patients undergoing simultaneous ETV and tumor biopsy was undertaken. Preoperative MR images were examined to measure the width of the anterior third ventricle and maximal diameters of the tumor, Monro foramen (right), and massa intermedia. The distances between the tumor and massa intermedia, tumor and anterior commissure, midbrain and massa intermedia, and the dorsum sella and anterior commissure were also recorded. Single and dual trajectory approaches were compared using paired t-tests for each parameter. Results Over an 8-year interval, 15 patients underwent simultaneous ETV and tumor management. These patients ranged from 6 to 71 years of age (mean 36.7 years); 5 were younger than 18 years of age. Seven were treated using a dual trajectory approach, and 8 were treated using a single trajectory approach. All cases were completed without complications or the need for an additional CSF diversionary procedure within 6 months. The diagnostic yield at biopsy was 86.7%. There were no statistically significant differences between the single and dual trajectory groups for the measured parameters. However, the dual trajectory group demonstrated a larger anterior third ventricular diameter (1.43 vs 1.21 cm, p = 0.29). The single trajectory group trended toward a smaller tumor–anterior commissure interval (2.23 vs 2.51 cm, p = 0.24) and a larger dorsum sella–anterior commissure distance (1.67 vs 1.49 cm, p = 0.28). Conclusions These data confirm the safety and diagnostic efficacy of simultaneous ETV and biopsy for tumors of the pineal region. Although no statistically significant differences were seen in the authors' recorded measurements, several trends suggest a role for a tailored approach to selecting a single or dual trajectory approach when using a rigid endoscope.

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Endoscopic biopsy of brain tumors in children: diagnostic success and utility in guiding treatment strategies

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.10.peds09172 ◽

2010 ◽

Vol 5 (3) ◽

pp. 255-262 ◽

Cited By ~ 39

Author(s):

Edward S. Ahn ◽

Liliana Goumnerova

Keyword(s):

Brain Tumors ◽

Tumor Marker ◽

Lateral Ventricle ◽

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Pineal Region ◽

Endoscopic Biopsy ◽

Neurological Deficits ◽

Third Ventriculostomy ◽

Consecutive Series

Object Endoscopic biopsy is an important minimally invasive method of diagnosis in the initial management of lesions in children with intraventricular and periventricular tumors. The procedure can be performed in conjunction with CSF-diverting procedures for obstructive hydrocephalus. The authors present their single-institution experience in a predominantly pediatric series with respect to diagnostic efficacy, utility in guiding treatment plans, and safety. Methods A retrospective review was conducted in a consecutive series of patients who underwent endoscopic biopsy of brain tumors during a 13-year period. Results There were 33 endoscopic biopsies in 31 patients (16 males and 15 females). The average age of the patients was 11.3 years, with a mean follow-up duration of 2.4 years. The majority of biopsies were performed in conjunction with CSF-diverting procedures, such as endoscopic third ventriculostomy or fenestration of the septum pellucidum. Overall, 23 (70%) of 33 biopsies were diagnostic, with results that directed subsequent treatment. When stratified by tumor location, biopsy samples obtained in the lateral ventricle or pineal region were more favorable toward a successful diagnosis than those in the thalamus or tectal region. In 4 cases, elevated CSF tumor marker levels led to modification of the diagnosis and appropriate adjustment of treatment. The endoscopic third ventriculostomy success rate was 82.4%. There were 2 major complications (6.1%), which resulted in neurological deficits. There were no procedure-related deaths. Conclusions Endoscopic biopsy is an effective means of diagnosis of brain tumors in children. The diagnostic power may be more favorable with tumors in the lateral ventricle or pineal region. Collection of CSF during the procedure for tumor marker analysis is an integral component of diagnosis.

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Pineal region tumors: Long-term results of endoscopic third ventriculostomy and concurrent tumor biopsy with a single entry approach in a series of 64 cases

Clinical Neurology and Neurosurgery ◽

10.1016/j.clineuro.2019.105418 ◽

2019 ◽

Vol 184 ◽

pp. 105418 ◽

Cited By ~ 4

Author(s):

Mohammad Samadian ◽

Ehsan Nazari Maloumeh ◽

Sepideh Shiravand ◽

Kaveh Ebrahimzadeh ◽

Guive Sharifi ◽

...

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Pineal Region ◽

Long Term Results ◽

Third Ventriculostomy ◽

Tumor Biopsy ◽

Pineal Region Tumors ◽

Single Entry

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Anterior endoscopic transcortical approach to a pineal region cavernous hemangioma

Neurosurgical Focus: Video ◽

10.3171/2021.4.focvid215 ◽

2021 ◽

Vol 5 (1) ◽

pp. V15

Author(s):

Jiuhong Li ◽

Jiaojiang He ◽

Lunxin Liu ◽

Liangxue Zhou

Keyword(s):

Cavernous Hemangioma ◽

Endoscopic Third Ventriculostomy ◽

Third Ventricle ◽

Pineal Region ◽

Postoperative Adhesion ◽

Third Ventriculostomy ◽

Back Side ◽

Coronal Suture ◽

The Third ◽

Transcortical Approach

A 57-year-old female presented with headache and dizziness for 3 months. Preoperative MRI revealed a lesion located at the pineal region and back side of the third ventricle, accompanied by hydrocephalus. The infratentorial supracerebellar approach may cause visuomotor, acousticomotor, and hearing disturbances. With the patient in a supine position, the authors used a frontal linear incision that was 3 cm anterior to the coronal suture and 2 cm away from the midline and an anterior endoscopic transcortical approach, which could achieve endoscopic third ventriculostomy, alleviating and preventing hydrocephalus due to postoperative adhesion and resection of the lesion at the same time. The pathological diagnosis was cavernous hemangioma. The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID215.

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Endoscopic Biopsy and Third Ventriculostomy for the Management of Pineal Region Tumors

World Neurosurgery ◽

10.1016/j.wneu.2014.11.013 ◽

2015 ◽

Vol 83 (4) ◽

pp. 543-547 ◽

Cited By ~ 20

Author(s):

Aminul I. Ahmed ◽

Malik J. Zaben ◽

Nijaguna V. Mathad ◽

Owen C.E. Sparrow

Keyword(s):

Pineal Region ◽

Endoscopic Biopsy ◽

Third Ventriculostomy ◽

Pineal Region Tumors

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Brain Tectal Tumors: A Flexible Approach

Operative Neurosurgery ◽

10.1093/ons/opy114 ◽

2018 ◽

Vol 16 (3) ◽

pp. E95-E100

Author(s):

Alessandro Perin ◽

Tommaso Francesco Galbiati ◽

Cecilia Casali ◽

Federico Giuseppe Legnani ◽

Luca Mattei ◽

...

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Good Prognosis ◽

Endoscopic Biopsy ◽

Third Ventriculostomy ◽

Histopathological Diagnosis ◽

Cerebrospinal Fluid Diversion ◽

Oncological Patients ◽

Slow Progression ◽

Benign Histology ◽

Midbrain Tumors

Abstract BACKGROUND AND IMPORTANCE Mesencephalic tectal gliomas represent a subset of midbrain tumors, which are more frequent in children than in adults. They usually become symptomatic when causing hydrocephalus by occluding the aqueduct. Because of their slow progression, due to their benign histology, they are characterized by a relatively good prognosis, although hydrocephalus might jeopardize patients’ prognosis. Treatment is usually represented by cerebrospinal fluid diversion associated or not with biopsy. CLINICAL PRESENTATION We report 2 illustrative cases of tectal gliomas in adults where endoscopic third ventriculostomy (ETV) and simultaneous endoscopic biopsy were obtained during the same operation by means of a single burr hole with a flexible endoscope. CONCLUSION We recommend using this overlooked neurosurgical tool for such cases, since it allows the surgeon to safely perform an ETV, then judge whether biopsy can be done or not, without harming the patient, and possibly achieving an important piece of information (histopathological diagnosis) to manage this subset of oncological patients.

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One- vs Two-Burr-Hole Technique for Combined Endoscopic Third Ventriculostomy and Pineal Region Biopsy: Volumetric Analysis of Brain at Risk

Operative Neurosurgery ◽

10.1093/ons/opaa010 ◽

2020 ◽

Vol 19 (2) ◽

pp. 175-180

Author(s):

Brandon D Liebelt ◽

Fangxiang Chen ◽

Antonio Biroli ◽

Xiaochun Zhao ◽

Peter Nakaji

Keyword(s):

At Risk ◽

Endoscopic Third Ventriculostomy ◽

Brain Parenchyma ◽

Pineal Region ◽

Burr Hole ◽

Third Ventriculostomy ◽

Tumor Biopsy ◽

Burr Holes ◽

The Brain ◽

The Ideal

Abstract BACKGROUND Pineal region tumors are associated with the ventricular system. Endoscopic third ventriculostomy (ETV) is often performed at the same time as tumor biopsy. OBJECTIVE To investigate the volume of brain possibly undergoing injury and forniceal stretching during ETV and tumor biopsy. METHODS We performed a retrospective review of preoperative magnetic resonance imagings (MRIs) and computed tomography (CTs) of patients with pineal region masses and used volumetric image-guided navigation to simulate a 1-burr-hole vs a 2-burr-hole approach through the brain parenchyma. We compared the volumes of parenchyma and fornix at the risk of injury. RESULTS The ideal entry point for ETV using 2 burr holes was a mean ± standard deviation (SD) of 25.8 ± 6 mm from the midline and 11.4 ± 9 mm behind the coronal suture. The ideal entry point using 2 burr holes for tumor biopsy was 25.7 ± 8 mm from the midline and 53.7 ± 14 mm anterior to the coronal suture. With 1 burr hole, the mean ± SD volume of brain parenchyma at risk was 852 ± 440 mm3. The volume of brain parenchyma at risk with 2 burr holes was 2159 ± 474 mm3 (P < .001; paired t-test). The use of 1 burr hole predisposed the fornix to 14 ± 3 mm of possible stretch, which was minimized with the 2-burr-hole approach. CONCLUSION Using 1 burr hole for both the ETV and tumor biopsy is less likely to traumatize the brain parenchyma than using 2 burr holes. However, 1 burr hole predisposes the fornix to stretch injury. We recommend tailoring the entry to each patient according to their anatomy rather than using a 1-size-fits-all approach.

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